Headline News in Healthcare is About Cost, Paperwork Reduction Rules Expected

Headline news in health care is usually about cost.  Now, we expect that by 2013 the entire industry will be required to provide quicker answers with less paperwork.   New rules that will help determine whether a patient can receive services from a health care provider according to their health plan, and the status of associated claims for those services are expected by 2013 if a new rule is finalized.

Last year we published a whitepaper noting that we expected gradual adoption of CAQH CORE rules with higher standards for determining patient eligibility and claim status via electronic systems.  In fact, complete eligibility information at the point of care, we predicted, would not be far off.

Headline news in the health care industry is finally arriving. July 30, 2011 the U.S. Department of Health and Human Services (HHS) published an interim final rule, which adopts operating principles developed by the Council for Affordable and Quality Healthcare’s Committee on Operating Rules for Information Exchange (CAQH CORE).

This is a first step toward implementation of an Affordable Care Act provision that cuts red tape in the health care system.   HHS estimates this will save $12 billion over ten years.

  • Whether a patient is eligible for coverage
  • The status of a health care claim submitted to a health insurer

The interim final rule issued requires compliance by health plans, health care clearinghouses, and certain health care providers by January 1, 2013.

The rule is the first of many that are expected, focused improvements to the health care system. Future rules, which will likely make headline news in healthcare, will address adoption of:

  • Electronic funds transfer and remittance advice;
  • A unique identifier for health plans;
  • A standard for health care claims attachments; and
  • Requirements that health plans certify compliance with all HIPAA standards and operating rules

The Office of the Federal Register posts rules for public inspection at this link: http://www.ofr.gov/inspection.aspx#special. The rule is set for publication on July 8, 2011. Comments will be accepted if submitted by 5:00 p.m. EDT September 6, 2011.

Expect revisions and extensions to HIPAA 5010, the new EDI standard to deal with this in the future.  Also, as ICD-10 CM becomes updated starting in 2014 there may be updates to diagnosis and procedure codes that support greater efficiencies.

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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.